Quality of care in many of the nation's nursing homes has been long recognized as inadequate despite efforts to reform and strengthen regulations. A more recent CMS policy initiative designed to improve quality relies on publication of nursing home quality report cards, which allow patients to easily compare relative quality ranking of competing nursing homes. Publication of such report cards is expected to provide nursing facilities with positive incentives to improve the quality of care they offer. Report cards may, however, also lead nursing homes to adopt "dysfunctional" strategies, such as "cream skimming" or "teaching to the test". Such strategies may adversely affect quality and access to nursing home care. The empirical evidence about the response of health care organizations in general, and nursing homes in particular, to such report cards is scant and inconclusive. In the proposed study we will examine the response of nursing homes to the publication of the CMS quality report cards and will answer two questions: 1) What factors determine which strategies nursing homes adopt in response to quality reports? And 2) what is the impact of such strategies on quality? The proposed study will compare data from the period prior to publication of the report to data from a period following publication to examine changes in behavior of nursing homes. We will create a comprehensive data set with information about: 1) the strategies that nursing homes adopted following publication and their views of the quality report cards (based on a national survey of nursing homes), 2) quality before and after publication of the reports measured along different dimensions, including those published in the reports, others that are not published, and hotel quality (based on MDS data merged with Medicare enrollment data and data on resource use obtained from nursing home cost reports) and 3) information about changes in admission profiles (MDS data). Statistical regression techniques will be used to analyze the data and test specific hypotheses.